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APPLICATION FOR SANITATION PERMIT Permit No. -------------­---- <br /> (Complete <br /> °_3_ --•----(Complete in Duplicate) <br /> Date Issued <br /> Application is hereby made to the San Joaquin Local Health District fora permifo tp-construot and ins all the Wort herein describ d: <br /> This application is made in compliance with County Ordinanc No. 54 —' ISO 0 <br /> JOB ADDRESS - �D'LOCATIOI_ 41- - � . <br /> -------- 7 <br /> _ R <br /> [- --------------------- -------______' ----------- <br /> Owner's Name------------ ------ ----------------------------------- - ---- --------------------------------------- Phone r <br /> Address------�J�---'"'i"cti <br /> ------------------------------------------------------------- <br /> r Contractor's Name-------- - � y ' <br /> Installation will serve: Residence [Apartment Hous ❑ Commercial ❑ Trailer Court g Motel [:1 Other [❑ <br /> JJ r f �.,. <br /> Number of living units: ______-_ Number of bedrooms .= _ Number aths __1____ Lot size _:T ____ <br /> Water Supply: Public system [] Community system ❑ Private Depth to Water Table ________ ft. <br /> Character of soil to a depth of 3 feet: Sand Gravel Sand Loam Clay Loam Clay l p ❑ ❑ Y ❑ Y ❑ y ❑ Adobe 0/Hardpan ❑ <br /> Previous Application Made: Yes ❑ No 811, New Construction: Ye`s-R(1No.0APHA%VA: Yes ❑ No ?""" <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: 1 4 <br /> (No septic tank or`cesspool permitted if ,uk�lic�>�se_w�er is available within 200 feet.) <br /> _ Septic Tank: Distance from nearest wel____�._;ststance from foundation__�95_____-_-_.Material______________ __________ <br /> No, of compartments____________ _ # <br /> S Liquid epth CapacityD � <br /> I p ` �� ;< ) <br /> Disposal Field: Distance from nearest well�or___ D stance from foundation____ Distance to nearest lot <br /> © Number of lines-----------ff-----_►_Z-_----_ Length of each line--------- ---- Width of trench-_------- if r__________ <br /> Type of filter materi6et*7 <br /> ----.---Depth of filter material-- ___�- _ f l <br /> -------.-Total length---- ------ ----- -'------------ <br /> _Seepage Pit: Distance to nearest well----------------------Distance fromOIL___-________.__..Distance to nearest lot line__ _._________ p <br /> I r y ElNumber of pits----------------------Lining material----------'---,;"--:Size: Diameter------------------------Depth---------------------- <br /> --------------- <br /> Cesspool: Distance from nearest <br /> f well________________Dstance frotm+�afoeu- <br /> ndation]_.-_______________.Lining material________________________.___________ <br /> Size: Diameter Depth` - ----------Liquid CaPacitY--- ----------- <br /> gals. <br /> Privy: Distance from nearest well_________---------------------- ---------------`Distance from nearest building__________._____----___________- <br /> ❑ Distance to nearest lot fine- -------------------------- <br /> Romode' g afid/or reing pair {d tribe)--------=-------------- <br /> ------------------------------------------------1-------------------------------------•----- <br /> -------------- ---- ---------•--------•---------------------------------- <br /> -----------------1------------------ j---------- <br /> -------------------------------------------------------------------'-------------•------------------------------------------------------------------ -----------------------------------•--------------------- <br /> -----------------------------------------------------------------------------------------=--------------•----------------------1-------- ------------i-------------------------------------------------------------------- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local',Health District. <br /> .. s l <br /> (Signed)---------- -- ----- --- ------------------------ ---.--(Owner and/or Contractor) <br /> BY , - --- ---°----------------------------------------------------- --'-------------------(Titie)--------------------------------------- ------------------------ <br /> (Plot plan, showi g s e of la location of-system in relation to wells, buildings, etc., can-be placed on reverse side). <br /> FOR DEPARTMENT USE QNLY <br /> I <br /> APPLICATION ACCEPTED BY - ------------------------------------------------ DATE <br /> REVIEWED BY ---------------------------- ---- ------------ DATE <br /> -- <br /> - -- ------------------------------------------- <br /> BUlLD1NG PERMIT ISSUED----------------- ----------------------------------------------------------------------------------- DATE--- . <br /> Alterations and/or recommendations: t --------------------------------------------------------­-------------------------------------------------------------------------- <br /> ---- ------ <br /> ----------------- <br /> ---------------------------------•----------- -- ---- ------------- ---------- 4 '�' ------------------------------------------------------------------------------------------------------------ <br /> tV. <br /> --- fir----=/ ---------------------•------------------------------•----------------------------------------- ------------------------------------ <br /> ------------ --------------------------------------------------- --------------------------------- <br /> ---------------- <br /> FINAL INSPECTION BY-------- --------------- ---------- ------ Date-------------- <br /> ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 Soufh American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-4-2M Revises 1-57 F.P.CO. <br />